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inn <br /> ,. . <br /> WELLRMIT APPLICATION F�dMjury <br /> .f <br /> G _ - MITIGATION <br /> SAN JOAQUIN COUNTY <br /> i <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) � 1V F 0 }I <br /> 304 E. Weber, Third Floor, Stockton,-CA., 95202 <br /> S� (209) 468-3449 FEB 4, 200: <br /> NON-REFUNDABLE PERM11 EXPIRES 1 YEAR FROM DATE ISSUED CCII��II11!!'���n�ppl� �F�y�yu <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application4S�tf �'it1 Ilai�{:eWlan <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health❑epartmeRERM;T�RVICES ! <br /> u Q ,} (� Cross Street Co��:e r City A LG�o► eg Zip N oma' P ra ce#or's <br /> WELL Location_a l 07� sU ��:e�� �-d' , <br /> PROPERTYOwnerbaoia + be6orak M.IterAfdidre-sus SaMe{y City eC Zip Phone# 3�S- 17 <br /> C-57 Contractor AC2F _Address Y+31 Shaw P-9City ST l� Zip NO Lic# Phane# yG -X00 <br /> Consultant/Sub Cntr Address CityLic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: a <br /> ,NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) �• <br /> jg,SOIL BORING# SD- 1 5 b-L OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3 r� MULTIPLE CASINGS7[]MULTI-LEVEL?a WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 13 HOSE <br /> []AIR SPARGE I Ozone 0 PUSH POINT GROUT SEAL PUMPED: [I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> SOIL BORING ) HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH y 0 BOLTED TRAFFIC BOX or 0 STOVEPIPE <br /> n 1 [� - CONDUCTOR CASING PROPOSED? Na (if YES,list specifications here): <br /> ^ ! <br /> "COMMENTS: Nov"n c lebt W 1. C'.n�on'te <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. j <br /> I hereby certify that I have prepared this appllcatioh and that the work will be done in accordance with San Joaquin <br /> - _ <br /> County OrdinaRees, Rubs and Regulations,and all applicable California State Laws.f I 1 A c <br /> an <br /> virOt►Men 1 P iGF:SI A&F- <br /> Signed x tvi � T'itlelComp y <br /> Print Na <br /> },o t+cr �• r .+��e C I Date O3--Oy- 03 <br /> DEPARTMENT USE ONLY ; <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> �� Area D 6 <br />� .. Date Issued <br /> Application Acxepted <br /> B <br /> Y <br /> y <br /> Grout Inspection B <br /> Date Final Inspection By Date <br /> - <br /> Destruction Inspection By - Date - <br /> COMMENTS I CONDITIONS, <br /> WC - <br /> # .YTS i"�`r.•:r`"' _ - ., , . , _ �,. `i. <br /> i€ UNT REMriTED CHECK# REC'D BY DATE �: PERMff f SERVICE REQUEST# INVOICE <br /> coR f C-57 Letter of Authorization to sign rmit�' Encroachment dor---. 8/29/02 <br /> I <br />